1. Two days after delivery, a postpartum client prepares for discharge. What
should the nurse teach her about lochia flow?
Incorrect: Lochia does
... [Show More] change color but goes from lochia rubra (bright red) on
days 1-3, to lochia serosa (pinkish brown) on days 4-9, to lochia alba (creamy
white) days 10-21.
Incorrect: Numerous clots are abnormal and should be reported to the physician.
Incorrect: Saturation of the perineal pad is considered abnormal and may
indicate postpartum hemorrhage.
Correct: Lochia normally lasts for about 21 days, and changes from a
bright red, to pinkish brown, to creamy white.
The color of the lochia changes from a bright red to white after four days
Numerous large clots are normal for the next three to four days
Saturation of the perineal pad with blood is expected when getting up from the
bed
Lochia should last for about 3 weeks, changing color every few days
2. A nurse monitors fetal well-being by means of an external monitor. At the
peak of the contractions, the fetal heart rate has repeatedly dropped 30
beats/min below the baseline. Late decelerations are suspected and the nurse
notifies the physician. Which is the rationale for this action?
Incorrect: A nuchal cord (cord around the neck) is associated with variable
decelerations, not late decelerations.
Incorrect: Variable decelerations (not late decelerations) are associated with
cord compression.
Incorrect: Late decelerations are a result of hypoxia. They are not reflective of
the strength of maternal contractions.
Correct: Late decelerations are associated with uteroplacental insufficiency
and are a sign of fetal hypoxia. Repeated late decelerations indicate fetal
distress.
The umbilical cord is wrapped tightly around the fetus' neck
The fetal cord is being compressed due to rapid descent of the fetal head
Maternal contractions are not adequate enough to deliver the fetus
The fetus is not receiving adequate oxygen and is in distress
3. Which preoperative nursing interventions should be included for a client who
is scheduled to have an emergency cesarean birth?
Incorrect: Monitoring O2 saturations and administering pain medications are
postoperative interventions.
Incorrect: Taking vital signs every 15 minutes is a postoperative intervention.
Instructing the client regarding breathing exercises is not appropriate in a crisis
situation when the client's anxiety is high, because information would probably
not be retained. In an emergency, there is time only for essential interventions.
Correct: Because this is an emergency, surgery must be performed quickly.
Anxiety of the client and the family will be high. Inserting an indwelling
catheter helps to keep the bladder empty and free from injury when the
incision is made.
Incorrect: The nurse should have assessed breath sounds upon admission.
Breath sounds are important if the client is to receive general anesthesia, but the
anesthesiologist will be listening to breath sounds in surgery in that case.
Monitor oxygen saturation and administer pain medication.
Assess vital signs every 15 minutes and instruct the client about postoperative
care.
Alleviate anxiety and insert an indwelling catheter.
Perform a sterile vaginal examination and assess breath sounds.
4. Which nursing instruction should be given to the breastfeeding mother
regarding care of the breasts after discharge?
Incorrect: Engorgement occurs on about the third or fourth postpartum
day and is a result of the breast milk formation. The primary way to relieve
engorgement is by pumping or longer nursing. Giving a bottle of formula
will compound the problem because the baby will not be hungry and will
not empty the breasts well.
Incorrect: Applying lotion to the nipples is not effective for keeping them soft.
Excessive amounts of lotion may harbor microorganisms.
Correct: In order to stimulate adequate milk production, the breasts should
be pumped if the infant is not sucking or eating well, or if the breasts are
not fully emptied.
Incorrect: Using soap on the breasts dries the nipples and can cause cracking.
The baby should be given a bottle of formula if engorgement occurs.
The nipples should be covered with lotion when the baby is not nursing.
The breasts should be pumped if the baby is not sucking adequately.
The breasts should be washed with soap and water once per day.
5. A client in preterm labor is admitted to the hospital. Which classification of
drugs should the nurse anticipate administering?
Correct: Tocolytics are used to stop labor. One of the most commonly used
tocolytic drugs is ritodrine (Yutopar).
Incorrect: Anticonvulsants are used for clients with pregnancy-induced
hypertension who are likely to seize.
Incorrect: The glucocorticoids (e.g., betamethasone and dexamethasone) are
used for accelerating fetal lung maturation and production of surfactant. They
are commonly used if the membranes are ruptured or labor cannot be stopped.
Incorrect: Anti-infective are used if there is infection. Preterm labor may or may
not involve ruptured membranes with its accompanying risk of infection. [Show Less]